Abstract

The bedside work of the intensivist is to provide adequate oxygen output to tissues in acute circulatory failure. The present chapter was the main reason for launching this new edition. We have taken care to make it as moderate and open as possible to any criticism. We just invite different thinking by introducing some thought processes in a field where no perfect “gold standards” are available. For this, we will propose the consideration of a parameter that can be as debatable as all the other tools, but whose particularity is to assess directly the question of fluid therapy. Evolution of concepts considering hemodynamic therapy in the critically iii Before intensive care units were created (in the 1950s–60s), patients with circulatory failure died. The physicians in charge of these new units did their best, helped only by the central venous pressure (CVP), until the Swan-Ganz catheter was developed in the early 1970s [1].

Appendix 1

Comments currently heard in our corridors:a

“This patient has already received 3,000 cc. I consider this is enough fluid.”

“What is a good hemodynamic tool? It depends. Probably all of them. If you have a PICCO in your institution and not the other tools, you will use the PICCO. If you have two tools, you can choose, case per case. This given patient will be better assessed using a TEE.”

“ I don’t believe too much in PICCO. What are my arguments? No precise argument, I just don’t believe in it.”

“I succeeded in maintaining this patient only at the price of massive doses of epinephrine and norepinephrine; he was definitely extremely severe.”

“I lost this patient in spite of massive doses of epinephrine and norepinephrine; he was definitely too severe.”

“Before sending the patient to CT (for a diagnosis), I stabilized him.”b

“ I don’t care about the first value of this measurement (CVP, diameter, etc.). What I care about is the evolution under my therapy.”

aAll these comments have been heard, here or there (and even said by the young author). They are not inserted here in order to highlight the ignorance of certain intensivists, but rather to show, by the text, that the traditional tools are all indirect ones.

bSupposedly, blindly

Appendix 2

Methods and patients of the lung part of the limited investigation (Adapted from [77]):

The ultrasound operators, blinded to the hemodynamic measurements, checked for pressure head at the correct location, catheter line flushed, zero level, radiography, appropriate pressure traces surrounding balloon inflation. Only the PAOP curve displaying characteristic and logic curves (respiratory variations of PAOP remaining under respiratory variations of pulmonary artery diastolic pressure) was considered. The patients remained connected to ventilators.

Appendix 3

Application of the Grotowski law to the limited investigation considering hemodynamic therapy:

A shocked patient has spontaneously little chance to survive. Admitted into a hospital of any quality and taken in charge by an intensivist of any quality, the chances or survival dramatically increase, from zero to maybe 60% in low-level institutions (called B-series), and to 75% in the best institutions of the world, using TEE, etc. (called A-series). These numbers are the author’s estimations. Accepting them, the differences between an A-series and a B-series ICU is roughly only 15 percentage points.

Let us suppose that a statistical study proves that, in a collective of shocked patients, systematic fluid therapy improves 51% or more of the patients – or the opposite, it will be concluded that these institutions would make more good than harm – or the opposite, in giving systematic fluid therapy. The 60% speculative rate is enhanced by one point.

Let us now introduce into these B-series institutions our simple gray-scale ultrasound unit. The simple analysis of the left heart contractility will give precious information on the need for inotropics, again enhancing the 60% rate by a few points.

Let us now introduce the FALLS protocol. Fluid given on the basis of A-predominance, and not given on the basis of B-predominance, would increase the rate of benefitial fluid administration – yielding additional points.

If we go on integrating simple data from our limited investigation, i.e., inferior and superior caval vein, etc., the B-series institution’s performance would be enhanced by these four, five, or more percentage points of bonus. A question is now opened: up to how many points will these B-series ICUs be hoisted? Didn’t they already reach the A-series ICUs? In this scenario, one speculates that, in those A-series ICUs, the definitive choice between either TEE, PICCO, PAC, or other tools will perhaps not be the critical point – as far as lung ultrasound is not used.